RT-LAMP Has High Accuracy for Detecting SARS-Cov-2 in Saliva and 2 Naso/Oropharyngeal Swabs from Asymptomatic and Symptomatic Individuals
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medRxiv preprint doi: https://doi.org/10.1101/2021.06.28.21259398; this version posted August 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 1 RT-LAMP has high accuracy for detecting SARS-CoV-2 in saliva and 2 naso/oropharyngeal swabs from asymptomatic and symptomatic individuals 3 Short title: RT-LAMP for detecting SARS-CoV-2 in saliva and naso/oropharyngeal swabs 4 †Stephen P. Kidd1,2, †Daniel Burns1,3, Bryony Armson1,2,4, Andrew D. Beggs5, Emma L. A. Howson6, 5 Anthony Williams7, Gemma Snell7, Emma L. Wise1,8, Alice Goring1, Zoe Vincent-Mistiaen9, Seden 6 Grippon1, Jason Sawyer10, Claire Cassar10, David Cross10, Tom Lewis10, Scott M. Reid10, Samantha 7 Rivers10, Joe James10, Paul Skinner10, Ashley Banyard10, Kerrie Davies11, Anetta Ptasinska5, Celina 8 Whalley5, Jack Ferguson5, Claire Bryer5, Charlie Poxon5, Andrew Bosworth5, Michael Kidd5,12, Alex 9 Richter13, Jane Burton14, Hannah Love14, Sarah Fouch1, Claire Tillyer1, Amy Sowood1, Helen Patrick1, 10 Nathan Moore1, Michael Andreou15, Nick Morant16, Rebecca Houghton1, Joe Parker17, Joanne Slater- 11 Jefferies17, Ian Brown10, Cosima Gretton2, Zandra Deans2, Deborah Porter2, Nicholas J. Cortes1,9, Angela 12 Douglas2, Sue L. Hill2, *Keith M. Godfrey18,19, +Veronica L. Fowler1,2 13 14 1Hampshire Hospitals NHS Foundation Trust, Department of Microbiology, Basingstoke and North Hants 15 Hospital, Basingstoke, UK 16 2NHS Test and Trace Programme, Department of Health and Social Care, UK 17 3School of Electronics and Computer Science, University of Southampton, UK 18 4vHive, School of Veterinary Medicine, University of Surrey, Guildford, UK 19 5University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 20 6The Pirbright Institute, Ash Road, Pirbright, Woking, UK 21 7University of Southampton & Division of Specialist Medicine, University Hospital Southampton, UK 22 8School of Biosciences and Medicine, University of Surrey, Guildford, UK 23 9Gibraltar Health Authority, Gibraltar, UK 24 10Animal and Plant Health Agency, New Haw, Addlestone, Surrey, UK 25 11Leeds Teaching Hospitals NHS Trust and University of Leeds, UK 26 12Public Health West Midlands Laboratory, Birmingham, UK 27 13Institute of Immunology and Immunotherapy, University of Birmingham, UK 28 14High Containment Microbiology, National Infection Service, Public Health England, Porton Down, UK 29 15OptiSense Limited, Horsham, West Sussex, UK 30 16GeneSys Biotech Limited, Camberley, Surrey, UK 31 17National Biofilms Innovation Centre, University of Southampton, UK 32 18NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital, UK 33 19MRC Lifecourse Epidemiology Centre, University of Southampton, UK 34 35 †Denotes co-first authorship; +Senior author; *Corresponding author: - [email protected]; 36 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. Page 1 of 43 medRxiv preprint doi: https://doi.org/10.1101/2021.06.28.21259398; this version posted August 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 37 Abstract 38 Previous studies have described RT-LAMP methodology for the rapid detection of SARS-CoV-2 in 39 nasopharyngeal/oropharyngeal swab and saliva samples. Here we describe the validation of an 40 improved sample preparation method for extraction free Direct RT-LAMP and define the clinical 41 performance of four different RT-LAMP assay formats for detection of SARS-CoV-2 within a large-scale 42 multisite clinical evaluation. 43 We describe Direct RT-LAMP on 559 swabs and 86,760 saliva samples and RNA RT-LAMP on extracted 44 RNA from 12,619 swabs and 12,521 saliva samples collected from asymptomatic and symptomatic 45 individuals across multiple healthcare and community settings. 46 For Direct RT-LAMP, we found a diagnostic sensitivity (DSe) of 70.35% (95% CI 63.48-76.60%) on swabs 47 and 84.62% (79.50-88.88%) on saliva, with diagnostic specificity (DSp) of 100% (98.98-100.00%) on 48 swabs and 100% (99.72-100.00%) on saliva when compared to RT-qPCR. Analysing samples with RT- 49 qPCR ORF1ab CT values of <25 and <33 (high and medium-high viral copy number, respectively), we 50 found DSe of 100% (96.34-100%) and 77.78% (70.99-83.62%) for swabs, and 99.01% (94.61-99.97%) 51 and 87.32% (80.71-92.31%) for saliva. For RNA RT-LAMP DSe and DSp were 95.98% (92.74-98.06%) 52 and 99.99% (99.95-100%) for swabs, and 80.65% (73.54-86.54%) and 99.99% (99.95-100%) for saliva, 53 respectively. 54 The findings from these evaluations demonstrate that RT-LAMP testing of swabs and saliva is 55 applicable to a variety of different use-cases, including frequent, interval-based testing of saliva from 56 asymptomatic individuals via Direct RT-LAMP that may otherwise be missed using symptomatic testing 57 alone. 58 59 60 Page 2 of 43 medRxiv preprint doi: https://doi.org/10.1101/2021.06.28.21259398; this version posted August 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 61 Author Summary 62 Rapid diagnostic testing at scale to identify and isolate symptomatic and asymptomatic individuals 63 potentially transmitting infectious SARS-CoV-2 is an essential part of the response to the COVID-19 64 pandemic. RT-LAMP on both extracted RNA and directly on crude samples potentially provides faster 65 turnaround times than reverse-transcriptase quantitative real-time PCR testing, with a higher 66 sensitivity and specificity than antigen lateral flow devices. Increasing evidence points to potential 67 benefits of SARS-CoV-2 testing using saliva rather than nasopharyngeal/oropharyngeal swabs, leading 68 us to undertake a multi-site evaluation of an improved simple sample preparation method for Direct 69 SARS-CoV-2 RT-LAMP. Our study demonstrated that the RNA RT-LAMP assay has high sensitivity and 70 specificity, providing a rapid alternative to RT-qPCR testing with a reliance on differing reagents and 71 equipment. The simple SARS-CoV-2 Direct RT-LAMP preparation method also demonstrated high 72 sensitivity and specificity for detecting SARS-CoV-2 in saliva and naso/oropharyngeal swabs from 73 asymptomatic and symptomatic individuals, notably in saliva samples from which the individual would 74 likely be considered infectious. The findings highlight the usefulness of saliva as a simple to collect, 75 non-invasive, sample type, potentially applicable for interval-based testing of asymptomatic 76 individuals. 77 Page 3 of 43 medRxiv preprint doi: https://doi.org/10.1101/2021.06.28.21259398; this version posted August 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 78 Introduction 79 Rapid diagnostic testing to identify and isolate symptomatic and asymptomatic individuals 80 potentially transmitting infectious viral pathogens is an essential requirement of any pandemic 81 response. The novel betacoronavirus, SARS-CoV-2, initially identified after an outbreak of viral 82 pneumonia in Wuhan, China in December 2019(1), has rapidly spread throughout the world, causing 83 over 141 million confirmed cases and over 3.1 million deaths(2), (April, 2021). 84 Conventional diagnostics for SARS-CoV-2 consist of RNA enrichment followed by reverse- 85 transcriptase quantitative real-time PCR (RT-qPCR) against one or more viral gene targets(3). 86 However, this methodology requires sample inactivation, RNA extraction and RT-qPCR thermal 87 cycling, meaning that the time from sample-to-result can often be several hours, and requires 88 centralised equipment and personnel trained in Good Laboratory Practice to perform testing. 89 We have previously shown the utility of reverse-transcriptase loop mediated isothermal 90 amplification (RT-LAMP) for the detection of SARS-CoV-2 both from extracted RNA (RNA RT-LAMP) 91 and directly from nasopharyngeal/oropharyngeal swabs (Direct RT-LAMP)(4). RT-LAMP utilises a 92 rapid and stable DNA polymerase that amplifies target nucleic acids at a constant temperature. This 93 removes the requirement for conventional thermal cycling allowing RT-LAMP reactions to be 94 performed in shorter reaction times using less sophisticated platforms. 95 In a study of 196 clinical samples(4), testing of RNA extracted from nasopharyngeal/oropharyngeal 96 swabs collected into viral transport media (VTM) using RNA RT-LAMP demonstrated a diagnostic 97 sensitivity (DSe) of 97% and a diagnostic specificity (DSp) of 99% in comparison to RT-qPCR of the 98 ORF1ab region of SARS-CoV-2. For Direct RT-LAMP on crude swab samples, the DSe and DSp were 99 67% and 97%, respectively. When a cycle threshold (CT) cut-off for RT-qPCR of < 25 was considered, 100 reflecting the increased likelihood of detecting viral RNA from active viral replication, the DSe of 101 Direct RT-LAMP increased to 100% (4). Page 4 of 43 medRxiv preprint doi: https://doi.org/10.1101/2021.06.28.21259398; this version posted August 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.